=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295921187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSOURCE HOME HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2114 NOBLE RD
-----------------------------------------------------
City | E CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44112-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-289-9112
-----------------------------------------------------
Fax | 216-289-9114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27801 EUCLID AVE 560
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44132-3549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-289-9112
-----------------------------------------------------
Fax | 216-731-8545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TERRY L MAYNARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-289-9112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------